Predicting outcome from coma: man-in-the-barrel syndrome as potential pitfall

The Glasgow coma scale motor score is often used in predicting outcome after hypoxic–ischemic coma. Judicious care should be exerted when using this variable in predicting outcome in patients with coma following hypotension since borderzone infarction can obscure the clinical picture. We describe a patient who underwent skull base surgery for a schwannoma of the left facial nerve. The operation, which lasted for 10 h, was conducted under controlled hypotension. After the intervention the patient remained comatose with absent arm movements upon painful stimuli. An absent motor score usually carries a poor prognosis. However, magnetic resonance inversion recovery imaging of the brain showed bilateral hyperintense lesions in the arm–hand area indicative of borderzone ischemic damage. The patient received optimal supportive care and after 17 days he regained consciousness with ‘man-in-the-barrel syndrome’, which also further improved over time.